Book Now To Get a Massage Therapy or Facial Treatment (786) 485-1709 info@atouchofheavenmassage.miami Services Massage Services Esthetic Services Massage Therapy Services INFORMED CONSENT & POLICIES CLIENT/THERAPIST RELATIONSHIP I avoid engaging in relationships with clients outside the professional environment as a dual relationship could potentially compromise the therapeutic relationship. CONFIDENTIALITY The therapeutic relationship between a client and me is important and personal. I honor the client's right to privacy and our work together is confidential. You can expect that all information gathered during a session will be held in confidence. HYGIENE You can expect a massage practitioner to wear professional attire and maintain good hygiene. Clients should arrive to the massage session in a state of good hygiene. INTOXICATION & PRESCRIPTIONS Because circulatory systems are affected during massage. it is absolutely necessary that clients not have alcohol in their system for the 12 hours leading up to the massage session. Clients under the influence of illegal drugs will pay the fee and have their session terminated. Clients taking prescription medications should alert me on the intake form so that certain techniques can be modified or avoided, if necessary. SEXUAL MISCONDUCT Due to differences in values according to culture, it is possible that a professionally intended touch could be interpreted as threatening or inappropriate. You may express — at any time during the massage session — that a touch is outside your comfort zone. You can expect — without exception — that your expressed desire will be respected. The client should not reach out to touch the practitioner in a threatening or sexual manner at any time PRIVACY & DRAPING You have the right to disrobe to your comfort level. It is common to disrobe down to the undergarments. Only the area being massaged will be exposed at any given time FEE STRUCTURE Payment is expected the day of an appointment unless prior arrangements have been made. Compensation to an unlicensed massage practitioner is not allowed in the State of Florida. Payment form is cash in US Dollars, unless otherwise specified. ON-SITE THERAPY: Massage therapy provided at a client's home or designated location. The session fee includes the travel time to and from the location, the equipment set-up time, and the massage application. The client may request a 60-minute session (1 hour), or a 90-minute session (1-112 hour). I, the undersigned, understand that the massage performed on my person is for the purpose of stress/tension reduction, relief from muscle tension, increased blood circulation, and a positive experience of structured, therapeutic touch. The general benefits of massage and possible massage contraindications have been explained to me. I understand and accept that the massage practitioner does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals. Manipulation of bone is not part of massage therapy. I understand that massage therapy is not a substitute for medical care and that it is my responsibility to work with my primary medical care provider for any medical condition I may have. I have stated all my known physical conditions and medications. I understand that withholding relevant medical information may result in my experiencing adverse effects. I have read and understood the above guidelines and agree to abide by them or forfeit massage therapy with this practitioner. SignatureName Printed Date MM slash DD slash YYYY A Touch of Heaven Therapeutic Massage CONFIDENTIAL - Client Intake FormFull Name Cell PhoneToday's Date MM slash DD slash YYYY Email Date of Birth: (m/d/y) MM slash DD slash YYYY Other PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact Name Emergency Contact PhoneIn order for me to best serve you, please provide the following information. Thank you.Are you presently under the supervision of a physician or naturopath? Yes No Physician's Name PhoneDid your physician recommend massage therapy? Yes No Please list all medications (OTC and Rx) that you are currently takingDo you have any history of: (circle) Cancer Lymphedema DVT/(Blood Clots) Are you currently receiving: (circle) Chemotherapy Immunotherapy Hormone/Therapy Radiation Please check any of the following conditions that you currently haveArthritis or tendonitis Yes No Infectious disease Yes No Asthma or lung problems Yes No Jaw pain or TMJ (facial/chewing issues) Yes No Blood clots (thrombosis/embolism) Yes No Ligament sprain or muscle strain Yes No Cancer or tumors Yes No Muscle or bone injury Yes No Chronic pain Yes No Numbness or tingling Yes No Face or head injury Yes No Pregnancy Yes No Fatigue Yes No Sciatica Yes No Heart or circulatory problems Yes No Skin condition (rash, eczema, etc) Yes No Hernia Yes No Surgery in past 12 months Yes No High blood pressure (hypertension) Yes No Tension and stress Yes No Other (please describe briefly)Essential Oils are used in some massage treatments. Would you like to have these oils applied? Yes No Please indicate your preference? Massage Oil Massage Lotion/Cream Doesn't Matter Tunderstand that I need to drink plenty of water after my massage treatment in order to flush out toxins from my body. Please initial here: PAYMENT FOR SERVICE IS DUE AT TIME OF SERVICE - CASH, DEBIT OR CREDIT CARDS ONLY. THANK YOU. **** ** PLEASE REMEMBER TO PUT YOUR CELL PHONE ON SILENT, FOR YOUR SAKE ** SignatureDate Signed MM slash DD slash YYYY A Touch of Heaven Therapeutic Massage CONFIDENTIAL INTAKE FORM – SKIN CARE/ESTHETICSName Date MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneWork/Cell PhoneProfession Email Address Date of Birth MM slash DD slash YYYY Emergency Contact PhoneHow did you hear about us? Advertisement? Family/Friend? Website? Internet Search? Other sourceHave you ever received professional skin care/esthetics treatments? Yes No If yes, what type Have you been under the care of any physician, dermatologist, or other medical professional within the past year? If so, please explain:List any medications, supplements, or herbal/homeopathic remedies you currently take:Are you using any topical medication or exfoliating acids like salicylic or glycolic? Yes No If yes, explain: Have you ever had an adverse reaction to a cosmetic product? Yes No If yes, explain: What are you currently using to cleanse and moisturize your face? Do you currently use any special treatments? (eye , scrubs, masks, etc.) How would you rate the overall quality of your skin? POOR FAIR GOOD VERY GOOD EXCELLENT What improvements would you like to see to your skin? When you got out in the sun, do you: (circle one) ALWAYS BURN USUALLY BURN SOMETIMES BURN RARELY BURN NEVER BURN How many glasses/cups of water do you drink daily? On a scale of 1-10, how would you rate your current stress level? 1 2 3 4 5 6 7 8 9 10 Have you ever been treated for: (Circle all that apply) Acne Depression Skin Disease High Blood Pressure Frequent Cold Sores Diabetes Skin CancerHormone Imbalance Hepatitis Herpes Skin Lesions Keloid Scaring Metal Bone Pins/Plates Do you wear contact lenses? Yes No and Are you wearing them now? Yes No If you wear a hormone or nicotine patch, please indicate which kind and where you wear it:Are you bothered by scents, oils or lotions? Yes No If yes, explain: Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid, or any Vitamin A/Retinol derivative? Yes No If yes, have you used these products within the last 3 months? Yes No Have you ever used an acne medication? Yes No If yes, when and which one? Have you ever had an allergic reaction to food, sunscreens, or AHAs? Yes No If yes, please explain: Skin Care Consent Form I certify that the above information is correct to the best of my knowledge. In accordance with the law, Esthetics/Skin Care Therapy cannot cure, treat, prevent or diagnose any condition. These treatments are used as ATOH – PAGE 3 regimens for improving skin appearance and wellness. Information exchanged during any session should be given at my own discretion. Because certain esthetics treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the skin care therapist updated as to any changes in my health prior to any future sessions and understand that there shall be no liability on the therapist’s part nor on the part of Integrative Life Solutions, Inc. and its affiliates should I fail to do so. The therapist reserves the right to refuse service to anyone for any reason. I fully understand that the therapist performs her services within the parameters of esthetics, using skin care treatments and therapies. I fully understand that the esthetics therapist is not an allopathic doctor, dermatologist, or psychiatrist and does not portray himself/herself to be. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the products and/or techniques may be adjusted to my level of comfort. By signing below, I acknowledge that I have read and understand all parts of this consent/intake form, and that I have had the opportunity to ask any questions with regard to any services or therapies offered. All client information is confidential.Client Name Printed Client SignatureDate MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
